Managing the Severe Cavus Foot Deformity in Global Humanitarian Programs.

The cavus foot represents a complex spectrum of deformity ranging from the subtle idiopathic to the severe sensorimotor neuropathy and other neuromuscular deformities. The successful surgical treatment of the cavus foot depends on a fundamental understanding of the underlying multiplanar deformity, inherent muscle balance, and the rigidity of the hindfoot. The location of the deformity is described and understood according to its multiple apices. These deformities are addressed with osteotomies or arthrodesis directed at the apices of deformity. Simultaneously, correction of muscular imbalances with appropriate tendon transfers must also be performed to prevent recurrent deformity. With these principles in mind, the surgical correction of the cavus foot becomes simplified and algorithmically driven.

Talocalcaneal coalition classifications: A critical analysis review and suggested new classification system with implications for treatment.

Talocalcaneal coalitions (TCC) is the second most frequent tarsal coalition reported. Our aim was to review talocalcaneal coalition classifications and to propose a new classification emphasizing a therapeutic approach. None of the classifications described for TCC mention the presence of flatfoot or valgus hindfoot, which are the key elements when defining the optimal treatment of this disease. We defined five clinical and radiological factors that would guide the choice of surgical treatment and based on these, we proposed a new classification system.

The Failed Cavovarus Foot: What Went Wrong and Why?

The adult cavovarus foot exists on a spectrum and, therefore, requires a thorough evaluation to determine the extent of the deformity and then choose from a multitude of surgical procedures to achieve correction. Regardless of the severity of the deformity, treatment should include an algorithmic approach to adequately achieve a stable, balanced, and plantigrade foot. To prevent failure, the surgeon should evaluate whether the deformity is flexible or rigid, determine the location of the apex or apices of the deformity, evaluate any muscle imbalances occurring about the foot and ankle, and determine the need for additional procedures. A failure to consider these principles and, subsequently, the extent of the deformity often results in recurrence and progression of the deformity.

Arthroscopic Anterior Talofibular Ligament Repair Combined With All-Inside Suture Tape Augmentation for Treatment of Chronic Lateral Ankle Instability With Generalized Joint Laxity.

BACKGROUND: To analyze the feasibility and clinical results of the modified Broström operation (MBO) combined with suture tape augmentation under arthroscopy for chronic lateral ankle instability (CLAI) in patients with generalized joint laxity (GJL). METHODS: From October 2019 to October 2021, a total of 111 patients (111 ankles) treated with MBO combined with suture tape augmentation under arthroscope were retrospectively divided into a GJL group (29 patients) and a control group (82 patients). Mechanical stability of the affected ankle joint was evaluated radiographically preoperatively, at 6 months postoperatively, and the last follow-up. Complications and surgical failures, as well as visual analog scale (VAS) score, the Foot and Ankle Ability Measure (FAAM), and the Karlsson score were also recorded. All statistical analyses were completed using SPSS 20.0. RESULTS: The average follow-up time was 21.7 ± 5.2 months for the GJL group, and 20.9 ± 5.3 months for the control group. Pain and symptoms in both groups were effectively relieved by the procedure reflected by decreased VAS scores, improved FAAM and Karlsson scores at 6 months postoperatively, and the final follow-up (P < .05). Preoperative talar tilt angle and anterior talar translation were significantly greater in the GJL group than those in the control group (P < .05). Postoperatively, both talar tilt angle and anterior talar translation were reduced in both groups at 6 months postoperatively and the last follow-up (P < .05), and we found no significant difference between the two groups (P > .05). Furthermore, we found no significant difference in VAS, FAAM, and Karlsson scores between the 2 groups 6 months postoperatively and at the last follow-up. CONCLUSION: Arthroscopic MBO combined with suture tape augmentation is a reliable procedure for treating CLAI with GJL. At short-term follow-up, we found that the GJL group achieved an equivalent level of stability compared with the control group.

Surgical correction of the ball and socket ankle joint in the adult associated with a talonavicular tarsal coalition.

BACKGROUND: Ball and socket ankle (BASA) deformity is a rare condition. Little is known about outcomes and treatments in the adult population. METHODS: Retrospective comparative review was performed of 13 patients treated for BASA with a minimum follow-up of 2.5 years. Evaluation included clinical and radiographic review, outcome scores, a questionnaire, and a subjective satisfaction survey. RESULTS: Nine patients with correctable valgus deformity not associated with arthritis of the ankle joint underwent a supramalleolar osteotomy (SMO). Four patients underwent arthrodesis-2 a tibiotalocalcaneal (TTC) arthrodesis and 2 a pantalar arthrodesis. AOFAS scores improved from 30.1 to 77.6 (range, 16-82) (P < .05) in the SMO group. AOFAS scores improved from 24 to 60.5 (range, 16-66) (P < .05) in the arthrodesis group. Arthritis grade in the SMO patients was unchanged in 4 patients at final follow-up and worsened in 5 patients by only 1 grade. Nine patients reported good results (all 4 arthrodesis patients, 5 SMO patients) and 4 reported fair results (all SMO patients). CONCLUSIONS: BASA deformity and dysfunction can be improved with corrective surgery. LEVEL OF EVIDENCE: Level III, prospective comparative study.

Osteochondral distal metatarsal allograft reconstruction: a case series and surgical technique.

BACKGROUND: Painful degenerative diseases of the metatarsophalangeal joints (MTPJs) are frequently progressive and difficult to treat. Traditional operative treatments such as debridement, distal metatarsal osteotomies, and arthroplasty present a unique set of complications, and pain and deformity may still occur. Osteochondral distal metatarsal allograft reconstruction (ODMAR) is presented as a salvage procedure, reserved for patients with significant bone loss or avascular necrosis in whom traditional interventions have failed or are inadequate to address the underlying joint deformity. METHODS: A retrospective review identified all ODMAR cases performed by the senior author over the past 10 years. Patient symptoms, satisfaction, and MTPJ range of motion were measured at each postoperative evaluation. Graft healing and subsequent degenerative changes at the MTPJ were observed at each visit with foot radiographs. The surgical techniques for both first and lesser metatarsal reconstructions are described. RESULTS: Six patients were identified with average follow-up interval of 36 months (range, 6-66). Preoperative diagnoses included infection (1), fracture (1), and avascular necrosis (4). Mean total arc of motion was 40 degrees (range, 30-50). All patients maintained viability of the allograft metatarsal head and joint space was normal or Kellgren-Lawrence grade 1 in 5 of 6 patients at final follow-up. All patients demonstrated osseous union of the metatarsal osteotomy site. No patients have undergone revision surgery to date. CONCLUSIONS: ODMAR is a safe and effective procedure for treatment of painful, degenerative conditions of the MTPJs. Further studies are required to determine the definitive indications and long-term outcomes for this procedure. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Ankle arthrodesis vs TTC arthrodesis: patient outcomes, satisfaction, and return to activity.

BACKGROUND: It is believed that patients with an ankle arthrodesis (AA) have better outcomes than after a tibiotalocalcaneal (TTC) arthrodesis due to preservation of subtalar motion. However, there are no studies comparing actual functional outcomes and patient satisfaction between AA and TTC arthrodesis. METHODS: We retrospectively analyzed patient satisfaction and functional outcomes of patients after an AA and TTC arthrodesis using a postal survey. A total of 173 patients who underwent TTC and 100 AA patients from 2002 to 2010 were identified with a minimum of 24 months follow-up. In all, 53 AA and 64 TTC arthrodesis patients were included in the study, with the remainder lost to follow-up. A return to activity questionnaire and SF-12 scores were used to compare functional outcomes. The mean follow-up time was 63 months. RESULTS: Both groups showed good outcomes with a low visual analogue pain score (2.7 for AA and 2.8 for TTC), high satisfaction score (90.6% for AA and 87.5% for TTC), and return to work (77.4% for AA and 73.0% for TTC). In all, 84.6% of AA and 81.0% of TTC patients would have the surgery again. There were no significant differences between the 2 groups for these parameters. However, when asked if their desired activity level was met, fewer AA patients met their desired level (58.5% for AA and 66.5% for TTC, P = .02). AA patients were also more likely to feel their level was unmet due to the foot and ankle (85.6% for AA vs 25.7% for TTC, P < .001). CONCLUSIONS: Both AA and TTC arthrodesis were associated with good functional outcomes and satisfaction. AA patients had higher postoperative activity expectations and were less likely to meet them. When they failed to meet these expectations, they were much more likely to attribute it to their operated ankle. We believe it is because of the different ways the 2 groups of patients are counseled preoperatively, which highlights the importance of managing patient expectations. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Tibiotalocalcaneal arthrodesis with bulk femoral head allograft for salvage of large defects in the ankle.

BACKGROUND: Tibiotalocalcaneal arthrodesis in patients with large segmental bony defects presents a substantial challenge to successful reconstruction. These defects typically occur following failed total ankle replacement, avascular necrosis of the talus, trauma, osteomyelitis, Charcot, or failed reconstructive surgery. This study examined the outcomes of tibiotalocalcaneal (TTC) arthrodesis using bulk femoral head allograft to fill this defect. METHODS: Thirty-two patients underwent TTC arthrodesis with bulk femoral head allograft. Patients who demonstrated radiographic union were contacted for SF-12 clinical scoring and repeat radiographs. Patients with asymptomatic nonunions were also contacted for SF-12 scoring alone. Preoperative, intraoperative, and postoperative factors were analyzed to determine positive predictors for successful fusion. RESULTS: Sixteen patients healed their fusion (50% fusion rate). Diabetes mellitus was found to be the only predictive factor of outcome; all 9 patients with diabetes developed a nonunion. In this series, 19% of the patients went on to require a below-knee amputation. CONCLUSIONS: Although the radiographic fusion rate was low, when the 7 patients who had an asymptomatic nonunion were combined with the radiographic union group, the overall rate of functional limb salvage rose to 71%. TTC arthrodesis using femoral head allograft should be considered a salvage procedure that is technically difficult and carries a high risk for complications. Patients with diabetes mellitus are at an especially high risk for nonunion. LEVEL OF EVIDENCE: Level IV, retrospective case series.

The Ludloff osteotomy: a review of current concepts.

The Ludloff osteotomy is a technique option to address hallux valgus in patients with a moderately to significantly increased first-second intermetatarsal angle. The Ludloff osteotomy is an oblique osteotomy of the first metatarsal extending dorsal-proximal to plantar-distal when viewed in the sagittal plane. The dorsal-proximal portion of the metatarsal is cut with the saw while maintaining the plantar-distal surface intact. A screw is inserted across the proximal aspect of the osteotomy, then the osteotomy is extended across the plantar surface distally. The metatarsal is rotated around the axis of the screw to the desired correction. In order to perform the osteotomy correctly, the surgeon must not only effectively complete the nuances of the technique, but also understand the limitations and contraindications of the Ludloff osteotomy. This review of current concepts for the Ludloff osteotomy reviews recent literature as well as technique pearls and pitfalls in the application of this powerful osteotomy.

Outcomes and Complications of Open Versus Minimally Invasive Repair of Acute Achilles Tendon Ruptures: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: An acute Achilles tendon rupture is one of the most common sports injuries, affecting 18 per 100,000 persons, and its operative repair has been evolving and increasing in frequency since the mid-1900s. Traditionally, open surgical repair has provided improved functional outcomes, reduced rerupture rates, and a quicker recovery and return to activities at the expense of increased wound complications such as infections and skin necrosis compared with nonoperative management. In 1977, Ma and Griffith introduced the percutaneous approach, and over the following decades, multiple improved techniques, and modifications thereof, have been described with comparable outcomes with open repair. PURPOSE: The current study aimed to provide updated level 1 evidence comparing open repair with minimally invasive surgery (MIS) through a comprehensive search of the literature published in English, Arabic, Spanish, Portuguese, and German while avoiding limitations of previous studies such as heterogeneous study designs and a small number of included trials. STUDY DESIGN: Meta-analysis; Level of evidence, 1. METHODS: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, 2 independent team members searched several databases to identify randomized controlled trials (RCTs) comparing open repair and MIS of Achilles tendon ruptures. The primary outcomes were (1) functional outcomes, (2) reruptures, (3) sural nerve injuries, and (4) infections (deep/superficial), whereas the secondary outcomes were (1) skin complications, (2) adhesions, (3) other complications, (4) ankle range of motion, and (5) surgical time. RESULTS: There were 10 RCTs that qualified for the meta-analysis with a total of 522 patients. Overall, 260 (49.8%) patients underwent open repair, while 262 (50.2%) underwent MIS. The mean postoperative AOFAS score was 94.8 and 95.7 for open repair and MIS, respectively, with a nonsignificant difference (mean difference [MD], -0.73 [95% CI, -1.70 to 0.25]; P = .14; I2 = 0%). The pooled mean total complication rate was 15.5% (0%-36.4%) for open repair and 10.4% (0%-45.5%) for MIS, with a nonsignificant statistical difference (odds ratio [OR], 1.50 [95% CI, 0.87-2.57]; P = .14; I2 = 40%). The mean rerupture rate was 2.5% (0%-6.8%) for open repair versus 1.5% (0%-4.6%) for MIS, with a nonsignificant statistical difference (OR, 1.56 [95% CI, 0.42-5.70]; P = .50; I2 = 0%). No cases of sural nerve injuries were reported in the open repair group. The mean sural nerve injury rate was 3.4% (0%-7.3%) in the MIS group, which was statistically significant (OR, 0.16 [95% CI, 0.03-0.46]; P = .02; I2 = 0%). The mean overall superficial infection rate was 6.0% (0%-18.2%) and 0.4% (0%-4.5%) for open repair and MIS, respectively, with a statistically significant difference (OR, 5.70 [95% CI, 1.80-18.02]; P < .001; I2 = 0%). The mean overall deep infection rate reported in the open repair group was 1.4% (0%-5.0%), while no deep infection was reported in the MIS group, with no statistically significant difference (OR, 3.14 [95% CI, 0.48-20.54]; P = .23; I2 = 0%). There were no significant differences between the open repair and MIS groups in the skin necrosis and dehiscence rate, adhesion rate, or keloid scar rate. The mean surgical time was 51.0 and 29.7 minutes for open repair and MIS, respectively, with a statistically significant difference (MD, 21.13 [95% CI, 15.50-26.75]; P < .001; I2 = 15%). CONCLUSION: Open Achilles tendon repair was associated with a longer surgical time, higher risk of superficial infections, and higher risk of ankle stiffness, while MIS was associated with a greater risk of temporary sural nerve palsy. The rerupture rate and functional outcomes were mostly equivalent. We found MIS to be a safe and reliable technique. However, high-quality standardized RCTs are still needed before recommending MIS as the gold standard for managing Achilles tendon ruptures.

Ligament augmentation repair is broadly applied across different orthopaedic subspecialities: an ISAKOS international survey of orthopaedic surgeons.

OBJECTIVES: To evaluate how ligament augmentation repair (LAR) techniques are currently used in different anatomic regions in orthopaedic sports medicine, and to identify the most common indications and limitations of LAR. METHODS: We sent survey invitations to 4,000 members of the International Society of Arthroscopy, Knee Surgery and Orthopaedic Sports Medicine society. The survey consisted of 37 questions total, with members only receiving some branching questions specific to their area of specialisation. Data were analysed using descriptive statistics, and the significance between groups was evaluated using chi-square tests of independence. RESULTS: Of 515 surveys received, 502 were complete and included for the analysis (97% completion rate). 27% of respondents report from Europe, 26% South America, 23% Asia, 15% North America, 5.2% Oceania, and 3.4% Africa. 75% of all survey respondents report using LAR, most frequently using it for the anterior talofibular ligament ( 69%), acromioclavicular joint ( 58%), and the anterior cruciate ligament (51%). Surgeons in Asia report using LAR the most (80%), and surgeons in Africa the least (59%). LAR is most commonly indicated for additional stability (72%), poor tissue quality (54%), and more rapid return-to-play (47%). LAR users state their greatest limitation is cost (62%), while non-LAR users state their greatest reason not to use LAR is that patients do well without it (46%). We also find that the frequency of LAR use among surgeons may differ based on practice characteristics and training. For example, surgeons who treat athletes at the professional or Olympic level are significantly more likely to have a high annual use of LAR (20+ cases) compared to surgeons that treat only recreational athletes (45% and 25%, respectively, p â€‹= â€‹0.005). CONCLUSION: LAR is broadly applied in orthopaedics but its rate of use is not homogeneous. Outcomes and perceived benefits vary depending on factors such as surgeon specialty and treatment population. LEVEL OF EVIDENCE: Level V.

Intra-articular opening medial tibial wedge osteotomy (plafond-plasty) for the treatment of intra-articular varus ankle arthritis and instability.

BACKGROUND: Although supramalleolar osteotomy with an opening medial wedge or a closing lateral wedge have been described for varus ankle deformity, these may be associated with failure due to persistence of the medial intra-articular defect, resulting in recurrent varus deformity. We report the results of a retrospective study assessing the outcome of an intra-articular opening wedge osteotomy of the distal medial tibia (plafond-plasty) for intra-articular varus ankle deformity associated with osteoarthritis and ankle instability. METHOD: The results of 19 plafond-plasties in 19 patients for correction of intra-articular varus osteoarthritis of the ankle associated with ankle instability were reviewed. Fourteen men and five women of a mean age of 47 (range, 32 to 63) years were treated. Followup ranged from 14 to 98 (mean, 59) months. RESULTS: Lateral ligament reconstruction was done at the time of the surgery in 18 out of 19 patients. The radiographic parameters including the TAS and TAL showed no statistical significant improvement when compared pre and post operatively. The varus ankle tilt deformity improved from 18 degrees preoperatively to 10 degrees postoperatively (p < 0.05). The pre- and postoperative AOFAS score improved significantly from 46 to 78, respectively (p < 0.05). Two patients underwent ankle arthrodesis at 7 and 36 months, and two patients underwent ankle replacement at 30 and 48 months following the index procedure. Of the remaining 15 patients, 14 reported stable or very stable ankles, and 15 of the 19 were either satisfied or very satisfied with the outcome of treatment. CONCLUSIONS: These results demonstrate that plafond-plasty osteotomy associated with lateral ligament reconstruction may be a suitable for patients presenting with intra-articular varus ankle osteoarthritis associated with ankle instability, providing pain relief and better function and stability in most patients.

Cement spacer as definitive management for postoperative ankle infection.

BACKGROUND: Postoperative infection can be a devastating complication of ankle replacement and arthrodesis surgery. Management consists of eradication of the infection and either, revision of the initial surgery or some form of salvage procedure. There are instances however when the patient is asymptomatic, medically unfit, or the local tissue is too tenuous to warrant performing additional surgery. We conducted a retrospective review of the outcome of the use of an antibiotic impregnated cement spacer as the definitive procedure in this kind of patient. METHODS: There were nine patients with post operative deep ankle infection following surgery who did not undergo subsequent revision surgery. The initial surgeries were either total ankle replacement (TAR) (n = 6) or ankle arthrodesis (n = 3). The indications for the retention of the cement spacer were patients who were asymptomatic following insertion of the cement spacer, did not desire further surgery, or were medically unfit for further surgery. The patients all underwent removal of hardware or implants, debridement, and insertion of an antibiotic impregnated cement spacer. Six weeks of intravenous antibiotics were administered according to culture sensitivity results. Patients were followed up closely for complications (wound dehiscence, spacer migration, bone loss), resolution of infection, functionality, and satisfaction. RESULTS: The average time of cement spacer retention was 20.1 months, ranging from 6 to 62 months. The most common infecting organisms were Staph. Aureus (n = 3) and Staph. Epidermidis (n = 3). One patient had wound complications, possibly due to the proximity of the cement spacer to the anterior skin surface. One patient had a repeat infection at 52 months. The most common co-morbidities were rheumatoid arthritis (n = 3) and diabetes (n = 2). At final followup, seven patients still had a retained cement spacer and two had subsequent below knee amputations (BKA) performed as a result of delayed complications. Review of the X-rays revealed two patients with loosening and migration of the cement spacer. No patients had signs of excessive bone loss. All patients with a retained antibiotic cement spacer were mobile and able to perform basic activities of daily living with minimal discomfort. CONCLUSION: The long-term use of antibiotic impregnated cement spacers following postoperative ankle infection is a reasonable option in the low demand patient with surgical or medical co-morbidities.

Midfoot arthrodesis following multi-joint stabilization with a novel hybrid plating system.

BACKGROUND: Several methods for fixation have been described for midfoot arthrodesis. Multi-joint arthrodesis at this level can be challenging because of bone loss and deformity, making it difficult to obtain a stable construct. We present the results of a novel hybrid plating system that incorporates locked and non-locked compression screws for multi-joint arthrodesis of the midfoot. METHOD: A retrospective multicenter review of patients undergoing multi-joint arthrodesis with hybrid plating of the midfoot was performed to evaluate the time to radiographic arthrodesis. Hybrid plating was defined as a construct that incorporates locked and non-locked compression screws. Neuropathy was the only exclusion criteria. Radiographic arthrodesis was defined as bridging bone on one of the three standard foot radiographs in the absence of a joint gap on the other views, or by 50% or greater bridging bone on computed tomography. Etiology of the arthritis, presurgical comorbidities, body mass index, functional level and postoperative complications were evaluated. RESULTS: Seventy-two patients were evaluated, and arthrodesis was obtained in 67 patients at 6 weeks in 27 patients, 9 weeks in 26, 12 weeks in 11, and at 16 weeks in three. In five patients at least one of the joints were not fused at 16 weeks and were considered a nonunion. Complications were present in 12 patients (17%). CONCLUSIONS: The healing rate and time to arthrodesis compared favorably to similar published studies. Based on these results, hybrid plating was a reliable and consistent alternative for fixation in midfoot arthrodesis, especially in multi-joint disease.

Surgical Management of the Undercorrected and Overcorrected Severe Club Foot Deformity.

Managing complications of clubfoot deformities can be very challenging. Some patients present with recurrent clubfoot and residual symptoms, and some present with overcorrection leading to a severe complex flatfoot deformity. Both can lead to long-term degenerative changes of the foot and ankle joints owing to deformity caused by unbalanced loading. This article only focuses on severe complications caused by recurrence and overcorrection in both children and adult patients.

Diagnostic Accuracy of the Progressive Collapsing Foot Deformity (PCFD) Classification.

BACKGROUND: A consensus group recently proposed the term progressive collapsing foot deformity (PCFD) and a new classification with 2 stages plus 5 classes to describe the complex array of flatfoot deformities. This study aimed to validate different diagnostic accuracy rates of the PCFD classification. METHODS: This was a survey-based study distributed among 13 foot and ankle fellowship programs for 3 groups of participants with varied experience in practice (group 1: fellows in training, group 2: surgeons in practice for 1-4 years, and group 3: surgeons in practice for ≥5 years). Each participant was asked to assign 20 different cases of flatfoot deformity to the appropriate classes and stages using the PCFD classification. The overall diagnostic accuracy, class, and stage diagnostic accuracy rates for the 20 cases were calculated first for the entire cohort and then compared among the 3 groups. The misdiagnosis rate for each class of deformity (the sum of overdiagnosis and underdiagnosis rates) of the entire cohort was calculated and compared with the other classes. Mean and standard evidence were used to describe numerical data. One-way analysis of variance was used to compare values among the 3 groups and the 5 classes. P <.05 was considered statistically significant. RESULTS: For the whole cohort, the overall diagnostic accuracy, class diagnostic accuracy, and stage diagnostic accuracy rates were 71.0%, 78.3%, and 81.7%, respectively There was a statistically significant difference between group 1 and 2, and group 1 and 3, in overall diagnostic accuracy and class diagnostic accuracy, with no significant difference among the 3 groups regarding stage diagnostic accuracy. Class B had a significantly higher overdiagnosis rate than the rest of the classes, whereas class D was significantly underdiagnosed than others. The misdiagnosis rates for classes A to E were 3.3%, 17.5%, 11.1%, 26.0%, and 3.7%, respectively. CONCLUSION: The PCFD classification showed overall fair diagnostic accuracy rates. The highest diagnostic accuracy was for "hindfoot valgus deformity" and "ankle instability." Further content validation of the PCFD classification is needed to examine the terminology and interpretation of those classes with low diagnostic accuracy including "midfoot/forefoot abduction deformity," "forefoot varus deformity/medial column instability," and "peritalar subluxation/dislocation."Level of Evidence: Level II, prospective comparative study.

Intra- and Interobserver Reliability of the New Classification System of Progressive Collapsing Foot Deformity.

BACKGROUND: Historical concept of flatfoot as posterior tibial tendon dysfunction (PTTD) has been questioned. Recently, the consensus group published a new classification system and recommended renaming PTTD to Progressive Collapsing Foot Deformity (PCFD). The new PCFD classification could be effective in providing comprehensive information on the deformity. To date, there has been no study reporting intra- and interobserver reliability and the frequency of each class in PCFD classification. METHODS: This was a single-center, retrospective study conducted from prospectively collected registry data. A consecutive cohort of PCFD patients evaluated from February 2015 to October 2020 was included, consisting of 92 feet in 84 patients. Classification of each patient was made using characteristic clinical and radiographic findings by 3 independent observers. Frequencies of each class and subclass were assessed. Intraobserver and inteobserver reliabilities were analyzed with Cohen kappa and Fleiss kappa, respectively. RESULTS: Mean sample age was 54.4, 38% was male and 62% were female. 1ABC (25.4%) was the most common subclass, followed by 1AC (8.7%) and 1ABCD (6.9%). Only a small percentage of patients had isolated deformity. Class A was the most frequent component (89.5%), followed by C in 86.2% of the cases. Moderate interobserver reliability (Fleiss kappa = 0.561, P < .001, 95% CI 0.528-0.594) was found for overall classification. Very good intraobserver reliability was found (Cohen kappa = 0.851, P < .001, 95% CI 0.777-0.926). CONCLUSION: Almost half (49.3%) of patients had a presentation dominantly involving the hindfoot (A) with various combinations of midfoot and/or forefoot deformity (B), (C) with or without subtalar joint involvement (D). The new system may cover all possible combinations of the PCFD, providing a comprehensive description and guiding treatment in a systematic and individualized manner, but this initial study suggests an opportunity to improve overall interobserver reliability. LEVEL OF EVIDENCE: Level III, retrospective diagnostic study.

The use of arthrodesis to correct rigid flatfoot deformity.

Rigid adult flatfoot deformity ranges in severity and is caused by a variety of conditions. Treatment is based on the etiology, the severity of symptoms, the stage of the deformity, and patient goals. Posterior tibial tendon pathology, osteoarthritis, posttraumatic arthritis/deformity, inflammatory arthropathy, and neuropathic arthropathy are all known causes of adult flatfoot deformity. Regardless of the cause, treatment goals are the same-restore a plantigrade foot, decrease symptoms, and increase function. When nonsurgical modalities have failed, many surgical reconstructive options are available to restore anatomy and function.

The management of complications following the treatment of flatfoot deformity.

Adult acquired flatfoot deformity encompasses a wide spectrum of clinical conditions. Current management approaches have emerged from a growing understanding of its manifestations, which have been learned from decades of clinical trial and error. Although surgical trends continue to evolve, many basic principles and practices have endured. Adult flatfoot deformity can arise from multiple causes, the most common of which remains posterior tibial tendon rupture with subsequent elongation of secondary supportive structures. Regardless of the cause, the fundamental goals of surgical management include correcting peritalar subluxation, restoring hindfoot-midfoot-forefoot relationships and muscle balance, attaining a plantigrade foot, and preserving motion when possible. Surgical correction may be associated with a variety of potential problems, including errors in decision making, undertreatment, overcorrection, and technical mistakes. These complications can lead to adjacent joint arthritis, recurrent deformity, rigidity, nonunion, and persistent pain.

Minimally invasive deltoid ligament reconstruction for stage IV flatfoot deformity.

BACKGROUND: Stage IV is the most advanced form of acquired adult flatfoot deformity (AAFD). It is present when valgus tibiotalar angulation occurs with foot deformities associated with AAFD. Tibiotalocalcaneal or pantalar fusion has been the gold standard for treatment of Stage IV AAFD. However, in some of these patients the tibiotalar deformity is correctable. We sought to determine whether minimally invasive deltoid ligament reconstruction in conjunction with triple arthrodesis (MIDLR/Triple) allows tibiotalar joint sparing surgical therapy in Stage IV-A AAFD patients. MATERIALS AND METHODS: Patients diagnosed with Stage IV-A AAFD were given the option of undergoing ankle joint sparing surgery with the MIDLR/Triple technique. Those that chose this option were followed longitudinally. Eight patients underwent the ankle joint sparing procedure. Average followup was 36 months. Radiographic and functional outcome measures were obtained. Success was defined as maintenance of 3 degrees or less of valgus tibiotalar angulation and greater than 2 mm of lateral joint space remaining at final followup. RESULTS: At final followup, five were judged to have a successful outcome. In those, tibiotalar valgus angulation was reduced from 6.4±2.9 degrees to 2.0±2.0 degrees, lateral ankle joint space was maintained at preoperative levels and SF-12 functional scores were equal to age matched normative scores. The only parameter found to be predictive of successful outcome was the magnitude of preoperative tibiotalar tilt. CONCLUSIONS: MIDLR/triple is a new treatment option that requires significant care in patient selection and surgical execution. It is a choice that allows for preservation of ankle motion in patients diagnosed with Stage IV-A AAFD who have less than 10 degrees of valgus tibiotalar tilt on preoperative standing ankle radiographs.